Provider Demographics
NPI:1134286750
Name:DERMOTT CITY NURSING HOME
Entity Type:Organization
Organization Name:DERMOTT CITY NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-538-5469
Mailing Address - Street 1:PO BOX 710
Mailing Address - Street 2:
Mailing Address - City:DERMOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71638-0710
Mailing Address - Country:US
Mailing Address - Phone:870-538-3241
Mailing Address - Fax:870-538-5763
Practice Address - Street 1:702 WEST GAINES ST.
Practice Address - Street 2:
Practice Address - City:DERMOTT
Practice Address - State:AR
Practice Address - Zip Code:71638
Practice Address - Country:US
Practice Address - Phone:870-538-3241
Practice Address - Fax:870-538-5763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR476314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR15172OtherBLUE CROSS BLUE SHIELD
AR045172Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER